=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871985127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ULSTER CORRECTIONAL FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 02/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 BERME RD
-----------------------------------------------------
City | NAPANOCH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12458-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-647-1670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 750 BERME RD PO BOX 800
-----------------------------------------------------
City | NAPANOCH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12458-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-647-1670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH SERVISE DIRECTOR
-----------------------------------------------------
Name | CHERIF MAKRAM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 845-647-1670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 008434
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------